Beyond the Word “Cancer”
Breast cancer surgeon and alum works for kinder, gentler treatment
In Margaret Duggan’s waiting room at Faulkner Hospital, it isn’t a nurse who comes to get the patient. It’s Duggan herself.
“Call me Peggy,” she says, and doctor and patient adjourn to a small, unremarkable office looking out on a leafy stretch of Centre Street in Jamaica Plain, Mass.
Duggan (CAS’86, MED’90), a surgeon and clinical director of the hospital’s Breast Centre, encourages patients diagnosed with cancer to bring someone along—a friend, her spouse, her mother. Sometimes they do.
“I once had six people in here,” says Duggan, who earned a bachelor of arts and a medical degree at Boston University and did surgical training at Boston Medical Center, then Boston City Hospital. Sometimes it helps.
“The real problem,” says Duggan, “is once they hear the word ‘cancer,’ they don’t hear anything else.”
Breast cancer is complex. Technically speaking, like all cancers, it is abnormal and uncontrolled cell growth, and it can be hard to define, yet a positive diagnosis changes the way a person thinks of herself: she becomes either a cancer patient or cancer survivor. Patients come to Duggan hoping to find a clear path through a barrage of confounding odds and confusing terminology: lobular carcinoma in situ. Operable stage IIC. Metastatic. Lymph node dissection. Trastuzumab. Bisphosphonates. Tyrosine-kinase inhibitor. Adjuvant therapy.
Duggan takes her time. “I explain the situation in the simplest terms,” she says. “I draw cartoons. It’s important for the patient not to feel like you’re hurrying her. They don’t need to decide anything today. I’ll say, go home and think about it.”
Writing in a medical blog, chick-lit novelist Laura Zigman (Animal Husbandry) describes her consultation with Duggan: “Dr. Margaret Duggan…took me into her office and spoke to me for over an hour,” writes Zigman. “She gave me an incredibly detailed and easy-to-understand mini-course that covered oncology and biology and genetics and surgery and statistics and probabilities and which included hand-drawn diagrams on a pad of paper which I actually understood.”
Sometimes, the women in her office sit silently, as if more time is needed to make sense of what’s happening. “People think they’ve been doing everything right,” says Duggan. “They feel that their body has betrayed them.”
Sometimes the women will ask her what she would do if she were the patient. “I’ll say, it doesn’t matter,” says Duggan. “That’s an emotional decision, and you want me to be dispassionate.”
Besides, she acknowledges, “honestly, I can’t say I would know what to do.”
Becoming one with a patient’s body
Over the course of a lifetime, one in eight women in the United States will develop invasive breast cancer. The disease—the most commonly diagnosed cancer among women—kills nearly 40,000 people a year, but there are upwards of 2.5 million survivors. We see these survivors, throngs of them, in well-organized marches, agitating for a cure. Multiply the emotional ordeal of each of Duggan’s 300 to 350 patients each year by 207,090—the estimated number of new cases of the disease diagnosed this year—and the fear is almost inconceivable.
While she is attentive to newer studies that shed light on breast cancer prevention, Duggan believes that breast cancer screening is “at the limits of its usefulness.” Tumors can lurk for years before they show up on mammograms, whose value is often overestimated or misunderstood. “There is no question that diminishing screening in women between 40 and 50 will lead to loss of life,” she says.
Although the incidence of breast cancer is low in this age group, the latest guidelines from a U.S. Department of Health and Human Services task force, which changed the starting age for annual mammograms from 40 to 50, might lull women into assuming routine mammography has no impact. “I can tell you many women benefit from mammograms in that age group,” she says. “So I would advocate for mammograms starting at 40, and the patient and her MD can decide if she needs one annually or every other year.”
Duggan prefers digital mammography, the new standard in Boston, which is easier to read and exposes the patient to less radiation. If breast cancer is curable, she says, it will be because of a highly nuanced combination of surgery and gene, hormonal, and other drug therapies. She sees hope in targeted therapies, hormonal therapy, and genetic markers—treatments custom-tailored to kill specific cancer cells or stop them from growing.
Duggan knows the forecasts she delivers daily can be confusing and infuriating, awash in percentages and probabilities, each number pregnant with hope or despair. The more state-of-the-art the treatment, the more a clinician struggles for clarity and absolutes, with diagnoses ranging from dire to concerning, from tumors that have metastasized to the bones to ambiguous early cell change known as carcinoma in situ, which may or may not become cancers.
There are six standard treatments for breast cancer, some offered in tandem. These are surgery—from breast-conserving lumpectomies to mastectomies—sentinel lymph node (the first lymph node to which cancer is likely to spread) removal and biopsy followed by surgery, radiation therapy, chemotherapy, hormone therapy, and cutting-edge targeted therapies, including monoclonal antibodies such as Herceptin, which blocks a cell growth factor protein and has none of the distressing side effects of chemotherapy.
Breast care at Faulkner involves a squadron of clinicians playing a role in diagnosis, treatment, and recovery, but among all these clinicians, it is the surgeon who is most hands-on, navigating the tissue and excising the actual, palpable cancer, which, Duggan says, is usually rock hard. In Abraham Verghese’s epic Cutting for Stone, a surgeon is described as becoming one with a patient’s body, which is the doctor’s “text, and he sounded it for the enemy within.” Such operating room intimacy is, thankfully, unavailable to patients. But in the time leading up to surgery, Duggan earns her patients’ trust and often their affection. She does 400 procedures a year, steering a clinical team that includes breast surgeons, medical oncologists, radiation oncologists, plastic and reconstructive surgeons, nurse practitioners, clinical nurse specialists, a social worker, and support staff. They all report to Duggan, who is beloved by her staff, according to her boss, chief of surgery Pardon Kenney, and equipped with both an Irish sense of humor and an Irish temper, and almost always prevails.
“She’s at home in a room full of surgeons, and though she does breast surgery, she’s kept up her interest in general surgery,” says Kenney, who considers Duggan, chosen one of Magic 106.7 radio’s Exceptional Women of 2011, a role model for women in surgery. “She shows them how to get it done.” Duggan herself is less likely to toot this particular horn, and both her sister, Mary Duggan, who works in Faulkner’s clinical education department, and Kenney say that while Duggan is tough, she hasn’t got much of an ego. She is not shy, and not above some old-fashioned mischief. One of Kenney’s favorite images is of his star surgeon whipping down Loon Mountain in a nun’s habit clutching a briefcase, along with similarly attired colleagues who make up the Nuns on the Run Team in the hospital’s annual Briefcase Race fundraiser.
A never-forgotten gift
The youngest of five children, Duggan grew up in a housing project in Chelsea, Mass., a small, struggling city across the Tobin Bridge where Boston proper’s gentrification screeches to what appears to be a permanent halt. “Our parents faced a lot of adversity,” says Duggan. “Both of them valued hard work of any kind. They encouraged us to go to school and become educated, and also to contribute to the world in a positive way. Somehow, they were always there for us, even though they both worked so hard.”
Theirs was a close family, and it was “a great experience growing up there,” Mary says. “Everybody knew each other.” Peggy “was an excellent student who did well in everything—a smart, smart girl,” and the children were “raised to be people who cared about other people.”
Their father was on the Chelsea police force for 30 years. Now widowed, he still lives there. Mary, the next to youngest, recalls a 10-year-old Peggy declaring, “I want to be a doctor.”
When it came time for college, her father didn’t want Duggan to leave Boston, but he didn’t have to worry: his daughter won scholarships to BU and Boston College. She chose BU, and landed a work-study job in the financial aid office. “The director at the time took an interest in me,” says Duggan, who worked hard in the office and managed great grades, too. “After the grades were released, he called me into his office and granted me room and board. It was a gift I’ve never forgotten.” She was one of 15 undergraduates accepted in a six-year medical program, beginning in her junior year. Duggan says she planned to become a primary care doctor, but a third-year rotation in surgery changed her mind. “I completely fell in love with the operating room,” she says. “I loved the culture there, and the types of diseases that were treated there with surgery.”
Elizabeth Cole (CAS’86), Duggan’s closest friend since sophomore year and now chair of women’s studies at the University of Michigan, says she owes her accomplishments in large part to her determined, focused friend. “I was the person who was more likely to get into trouble, and Peggy put an end to that,” recalls Cole. Peggy set strict schedules for studying and for fun, with studying getting the lion’s share.
“She always had a plan,” Cole says. Duggan lived in Towers and headed for the library every night after dinner. “She always knew what she wanted and she brought structure to my life.” The two were inseparable, says Cole, and still manage a visit at least once a year.
A sea change in the last decade
After a brief stint as a general surgeon in a private practice in Maine, Duggan returned to Boston to do a breast surgery residency at Boston Medical Center. One day she was asked out by a nurse named Joe.
“He made dinner for her,” Cole recalls. “He’s an ambitious cook and bought special place mats and place settings for the occasion.” Their courtship went fast, and they were engaged a year later. “But that’s how Peggy is,” says Cole. “She knows what she wants. She has a really correct internal compass, a real sense of herself.”
The couple had a fall wedding at Marsh Chapel, followed by a reception at the Castle. These days Joe works as a substitute school nurse, but is mostly home caring for their three adopted children, including twins from Cambodia. Close in age, the children were all toddlers together, which was “pretty intense,” says Cole. Now, she adds, “it’s a party.”
Duggan arrived at Faulkner, a leader in breast cancer research as well as treatment, in spring 1999. She was signing on with “the oldest breast center in Boston,” says Kenney. Started in 1987 by Susan Love, a breast specialist whose books and high media profile made her synonymous with breast cancer awareness, the clinic draws patients from other states, even other countries. Duggan, who is serving a two-year term as president of the Faulkner medical staff, spends one day a week at Boston’s Dana-Farber Cancer Institute.
Taking the position at Faulkner, the hospital where she was born, meant Duggan could remain in the city she loves, with family all around, and make a difference as an administrator and a clinician. The field has undergone a sea change in the last decade alone, she says. Today’s research focus is completely different from the way it was in her early days as a clinician, and she finds the transformation encouraging.
“It used to be that the guys in the lab were separate from the patients in the clinic,” she says. “The tissue samples would go to the guys in the lab, who you didn’t talk to. But now there’s a translateral reach. Every step of the way, the question is, how will the results affect this particular woman. The research now has the patient in mind. We have people in the lab who spend days with me in the clinic.”
Duggan’s repertory company of doctors, nurses, and counselors works in tandem to get the best results in the three areas of concern: morbidity, survival, and selective therapy. Her personal bias is the less surgery the better. “We do much less lymph node surgery than we used to, and we get just as much, if not more, information,” she says.
There are still many miles to go. “I’d love to tell women after surgery that we’ve excised their cancer completely and not have to wait” for the pathology report. And it’s unnerving to oncologists and surgeons that with carcinoma in situ there is no way to know which women will get cancer and which will not. Duggan knows that they could be overtreating many women, doing procedures that harm the body but don’t prolong life, but for now at least, she is unwilling to gamble on patients’ futures.
Cancer of the breast, which can be surgically removed, doesn’t kill people: it’s the spread of cancer to the lungs, liver, and bones that kills people. Duggan and others are working to fine-tune systemic treatment to prevent breast cancers from spreading. They’re on a mission to locate targets in the many subtypes of breast cancer. And lately they’ve got a promising ally in the drug Herceptin, a custom-made antibody that blocks the effects of a protein called HER2, which signals breast cancer cells to reproduce. Nearly a fourth of breast cancer patients have tumors that respond to Herceptin treatment combined with standard chemotherapy. In and of itself Herceptin “has no chemotherapy side effects, with a 10 percent increase in survival,” says Duggan. “But in oncology we say, for 2 percent we’ll change everything.”
At the Unitarian Meeting House in Wayland, Mass., where Duggan has served on the board for three years, she has another circle of admirers. They see the same intelligence, wit, and willingness to pitch in despite her crazy schedule that impress colleagues at Faulkner, but they also see something else.
“At church we are our whole selves, not just a doctor, not just a mother,” says Ann Gordon, chair of the church board. “Peggy brings her whole self on Sundays, which means opening herself up to absorb and reflect the emotions of any given moment.” It’s during those Sunday services, her friend notes, that Duggan sometimes does something her patients never see. She weeps.2 Comments